Conclusion

Available data suggest that exposure to PIs increases the risk of MI to a degree that depends on the duration of exposure. Howev­er, the rate of MI remains low and the risk­benefit ratio of PIs remains positive, as the increase in life expectancy conferred by cART far outweighs the associated risk of MI.

In keeping with current guidelines [5, 53, 54], the risk of CHD must be taken into account in antiretroviral treatment deci­sions, especially for patients with known vascular risk factors. Factors significantly associated with MI are older age, smoking either currently or formerly, previous car­diovascular disease, and male sex, but not a family history of CHD [29]. A higher total serum cholesterol level, a higher triglyc­eride level, and diabetes mellitus were also associated with an increased incidence of MI [29]. However, changes in lipid metabo­lism are different according to the different combined antiretroviral and the adverse events associated with antiretroviral treat­ment are different according to the drug regimen [55-58]. Thus, cholesterol, triglyc­eride, and blood glucose levels must be determined before and regularly during cART in order to diagnose any abnormali­ties as they occur and to manage the risk by following guidelines on the general popula­tion. In the DAD study, which compares the impact of two strategies of treatment, lipid lowering therapy (LTT) or switching from PI to a NNRTI (switch), versus a control group (no changes to therapy) [59], lipid changes were better with LTT or switch than the con­trol group.

It is also necessary to keep in mind that the fight against CHD includes action on modifiable risk factors such as smoking, dia­betes mellitus, arterial hypertension, and lipid disorders. Chiuve et al. have recently showed that 62% of CHD events were poten­tially preventable via adherence to healthy lifestyle practices [61]. Therefore, preven­tion should be promoted among patients with CHD risk factors even if it is unclear if risk will continue to rise with use of inter­vention. Nevertheless, in one study, time trends indicated changes in CHD risk fac­tors, especially a decrease in the percentage of smokers and individuals with high choles­terol among HIV-seropositive patients bet­ween 2000 and 2005 [62].

Longer follow-up of PI therapy is needed in order to tell whether the risk of MI contin­ues to increase with the duration of PI expo­sure. Moreover, further studies are necessary to confirm the association evidenced for aba- cavir and didanosine on CHD observed in the DAD study [39, 40] and to determine the impact of new therapeutic classes.

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